Provider Demographics
NPI:1437222668
Name:OLENICK, KELLEY J (AUD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:J
Last Name:OLENICK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 YELLOWSTONE AVE
Mailing Address - Street 2:PINE RIDGE MALL
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2345
Mailing Address - Country:US
Mailing Address - Phone:208-238-0020
Mailing Address - Fax:208-238-0021
Practice Address - Street 1:4155 YELLOWSTONE AVE
Practice Address - Street 2:PINE RIDGE MALL
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2345
Practice Address - Country:US
Practice Address - Phone:208-238-0020
Practice Address - Fax:208-238-0021
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDH-243237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010141365OtherREGENCE BCBS
ID0174362OtherWA DEPT OF LABOR
IDAU-456OtherBLUE CROSS OF ID
IDAU-449OtherBLUE CROSS GRP #AU-365
ID000010150424OtherBLUE SHIELD OF ID
IDAU-449OtherBLUE CROSS GRP #AU-365